Comprehensive Coronary Artery Disease Care in a Safety-Net Hospital: Results of Get With The Guidelines Quality Improvement Initiative
AUTHORS: Mori J. Krantz, William A. Baker, Raymond O. Estacio, Deborah K. Haynes, Philip S. Mehler, Gregg C. Fonarow, Carlin S. Long
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SUMMARY: Background: Adherence to published coronary artery disease (CAD)
guidelines is suboptimal, particularly among minorities and the poor. While
hospital-based quality-improvement programs may increase the use of
evidence-based therapies, little data exist regarding the impact of such
programs in sociodemographically disadvantaged (vulnerable) populations.
Vulnerable patients in the United States are cared for primarily within the
safety-net health system, which comprises urban public hospitals and
outpatient community health centers. Denver Health is an example of an
integrated system that encompasses both types of facilities.
Objective: To assess evidence-based medication use in CAD patients after
initiation of an inpatient quality-improvement program at Denver Health.
Methods: We reviewed the medical records of 499 patients with
angiographically proven CAD who were hospitalized between July 1998
and December 2002. Patients were prospectively identified through a
multidisciplinary intervention led by a nurse manager, and their records
were input retrospectively into the American Heart Association’s Get With
The Guidelines patient management tool. The association’s program, which
recommends initiating 4 cardioprotective drug classes while patients are
hospitalized, was started 2 years into the observation period (August 2000).
Treatment rates were compared over the ensuing years.
We evaluated temporal trends in discharge use of 4 drugs: (1) betablockers,
(2) angiotensin-converting enzyme inhibitors (ACEIs), (3) hydroxymethylglutaryl
coenzyme A reductase inhibitors (statins), and (4) aspirin. We
calculated the proportion of eligible patients (no documented contraindication)
who were prescribed each drug category as well as the proportion who
received all 4 drug categories, our principal composite outcome. If any one
drug was absent, the composite criterion was considered unmet.
Results: We observed progressive improvement in discharge use of the 4-
drug composite: 18% in 1998-1999 (95% confidence interval [CI], 12%-25%),
50% in 2000 (95% CI, 37%-63%), 62% (95% CI, 54%-70%) in 2001, and 72%
(65%-79%) in 2002 (P <0.001 for between-year differences). Among eligible
patients discharged in 2002, 90% received beta-blockers, 91% received
ACEIs, 86% received statins, and 93% received aspirin.
Conclusions: Implementation of a multidisciplinary program led by a nurse
manager was associated with increased CAD guideline compliance among
sociodemographically disadvantaged patients. This compliance exceeded
national averages. Achievement of the composite measure of use of all 4
recommended drug categories at discharge improved from 18% in 1998-1999
to 72% in 2002.
Keywords: Coronary artery disease, Get With The Guidelines, Safety-net